These changes in the uterus caused by extra-uterine pregnancy, which naturally extend to the cervix as well, especially its increased size and decidua, are of great practical value in forming a diagnosis in case of a doubtful pelvic tumor.
The uterus may be of varying size, and it may be stated that the nearer an extra-uterine ovum is developed to it, the more regularly will the uterus participate in development.
In interstitial pregnancy the uterus is from four to seven inches in length, from two to six inches in breadth, in thickness of its walls from to 11 inches; the wall is thickest on the impregnated side.
In tubal pregnancy development of the uterus does not regularly follow, and we quote Hennig who says, that in six cases the uterus was the same as it would be in unimpregnated women, and two of the cases were in young girls. Generally Hennig found the uterus enlarged; seven times slightly enlarged, eighteen times positively increased, five times double and once three times its normal size. He describes it as usually smaller than in interstitial pregnancy.
In tubo-abdominal pregnancy the uterus follows the same course, but not to the same extent as in interstitial and tubal pregnancies, and is usually found as it would b3 in the third or fourth month of pregnancy.
Ordinarily the form of the uterus is similar to normal. With the development of the organ the cervix becomes decidedly increased, and this we have observed in two cases.
Fig. 15 represents a section of a uterus of a seven months' tube abdominal pregnancy. The uterus is five inches long, 31 inches in breadth, the walls of the body to 1 inches in thickness. From the point of attachment of the peritoneum p p' downwards, the wall suddenly becomes thinner, and at the os ex ternum it is of an inch. The length of the thin-walled portion was two inches. The inner surface from a a' to b is 11 inches in length and covered by a thin decidua; the cervical mucous membrane begins with a very sharp edge at b b'. We have con vinced ourselves, by the examination of a number of virgin uteri, that the upper edge of the cervical mucous membrane is opposite the point of attachment of the peritoneum to the uterus, so it must be that that part of the uterus from a a' to b b' is the first to develop in early pregnancy.
In this way we explain the changes in the cervix noticed in women that have been pregnant a number of times. Under these circumstances the ovum may find its point of attachment as low as b b' If this is the case, the greater portion of the uterus which we, in the unimpregnated condi tion of the organ, describe as the cervix, is during early pregnancy drawn into that portion of the uterus which contains the ovum. We wish to emphasize the fact that these facts hold only for the large proportion of multiparEe (vide Fig. 12).
In three other cases of tubo-abdominal pregnancy we found the uterus 4i, and five and six inches long.
The position of the uterus varies greatly according to the locality of the ovum. It is usually between the third and fourth months, when extra uterine pregnancy gives rise to severe symptoms, that the cases seek medical assistance, and then the ovum has sunk down in Douglas's cul-de sac; the uterus is pushed up and more or less to one side, so that often we can feel its contour through the abdominal wall. So it was in two cases which we had the opportunity to observe in Professor Karl. Braun's clinic. In one case the vaginal portion was closely pressed against the symphysis, in another case it was pushed above the symphysis and difficult to reach; the same was present in two other instances which we examined. By further development the ovum, providing it has not contracted too ex tensive adhesions, w'll rise out of the pelvic cavity; and the uterus, which formerly held a high position, later becomes sunken below the edge of the ovum, or the ovum from the beginning is situated at a point where it will not sink into Douglas's cul-de-sac. In a case where pregnancy had gone to term we found the uterus, as is frequently the case in larger ova rian cysts, anteverted and somewhat to one side.
Symptoms of Extra-uterine Pregnancy.—At the beginning, as a rule, extra-uterine pregnancy manifests itself only by intrauterine symptoms. Usually the women do not doubt that they have conceived, and consider themselves normally pregnant. Sometimes, during the early months, they have no idea that they are pregnant; such was the case represented in Fig. 10.